

<table>
	<tbody>
		<tr>
			<td>
				<label>Full Name</label>
			</td>
			<td>
				[text* full-name akismet:author]
			</td>
		</tr>
		<tr>
			<td>
				<label>Address</label>
			</td>
			<td>
				[text address]
			</td>
		</tr>
		<tr>
			<td>
				<label>Phone</label>
			</td>
			<td>
				[text phone]
			</td>
		</tr>
		<tr>
			<td>
				<label>Email Address</label>
			</td>
			<td>
				[email your-email akismet:author_email]
			</td>
		</tr>
		<tr>
			<td>
				<label>Best time to contact you?</label>
			</td>
			<td>
				[text time]
			</td>
		</tr>
		<tr>
			<td>
				<label>What type of bills do you have?<br/>(Check all that apply)</label>
			</td>
			<td>
				[checkbox type-bills "Credit Cards" "Medical Bills" "Judgments" "Student Loans" "Tax Debts" "Government Fines" "Personal Loans"]
			</td>
		</tr>
		<tr>
			<td>
				<label>Number of bills</label>
			</td>
			<td>
				[text number-bills]
			</td>
		</tr>
		<tr>
			<td>
				<label>Amount owed</label>
			</td>
			<td>
				[checkbox amount-owed "Under $5,000" "$5,000 - $10,000" "$10,000 - $15,000" "$15,000 - $20,000" "$20,000 - $30,000" "$30,000 - $40,000" "$40,000 - $50,000" "Over $50,000"]
			</td>
		</tr>
		<tr>
			<td>
				<label>Appoximate value of home</label>
			</td>
			<td>
				[text value-home]
			</td>
		</tr>
		<tr>
			<td>
				<label>Approximate balance on mortgage</label>
			</td>
			<td>
				[text mortgage-balance]
			</td>
		</tr>
		<tr>
			<td>
				<label>Monthly mortgage payment</label>
			</td>
			<td>
				[text mortgage-payment]
			</td>
		</tr>
		<tr>
			<td>
				<label>Are you up to date on your mortgage payments?</label>
			</td>
			<td>
				[radio mortgage-up-to-date "Yes" "No"]
			</td>
		</tr>
		<tr>
			<td>
				<label>Are there any other mortgages on this property?</label>
			</td>
			<td>
				[radio mortgage-any-other "Yes" "No"]
			</td>
		</tr>
		<tr>
			<td>
				<h3>Vehicle 1</h3>
			</td>
			<td>
				
			</td>
		</tr>
		<tr>
			<td>
				<label>Year/Make/Model</label>
			</td>
			<td>
				[text vehicle-1-ymm]
			</td>
		</tr>
		<tr>
			<td>
				<label>Approximate Value</label>
			</td>
			<td>
				[text vehicle-1-value]
			</td>
		</tr>
		<tr>
			<td>
				<label>Approximate Balance</label>
			</td>
			<td>
				[text vehicle-1-balance]
			</td>
		</tr>
		<tr>
			<td>
				<label>Monthly Payment</label>
			</td>
			<td>
				[text vehicle-1-payment]
			</td>
		</tr>
		<tr>
			<td>
				<label>Are your payments up to date?</label>
			</td>
			<td>
				[radio vehicle-1-payment-up-to-date "Yes" "No"]
			</td>
		</tr>
		<tr>
			<td>
				<h3>Vehicle 2</h3>
			</td>
			<td>
				
			</td>
		</tr>
		<tr>
			<td>
				<label>Year/Make/Model</label>
			</td>
			<td>
				[text vehicle-2-ymm]
			</td>
		</tr>
		<tr>
			<td>
				<label>Approximate Value</label>
			</td>
			<td>
				[text vehicle-2-value]
			</td>
		</tr>
		<tr>
			<td>
				<label>Approximate Balance</label>
			</td>
			<td>
				[text vehicle-2-balance]
			</td>
		</tr>
		<tr>
			<td>
				<label>Monthly Payment</label>
			</td>
			<td>
				[text vehicle-2-payment]
			</td>
		</tr>
		<tr>
			<td>
				<label>Are your payments up to date?</label>
			</td>
			<td>
				[radio vehicle-2-payment-up-to-date "Yes" "No"]
			</td>
		</tr>
		<tr>
			<td>
				<label>Enter any other property of significant value. <br />(For example, if you own a boat, list it here.)</label>
			</td>
			<td>
				[textarea other-property]
			</td>
		</tr>
		<tr>
			<td>
				<label>Are you employed?</label>
			</td>
			<td>
				[radio employed "Yes" "No"]
			</td>
		</tr>
		<tr>
			<td>
				<label>How often do you get paid? </label>
			</td>
			<td>
				[checkbox frequency-paid "every week" "every 2 weeks" "twice a month" "monthly"]
			</td>
		</tr>
		<tr>
			<td>
				<label>Net Pay: (after taxes, medical and other deductions)</label>
			</td>
			<td>
				[text net-pay]
			</td>
		</tr>
		<tr>
			<td>
				<label>What other types of income do you have?  (Check all that apply) </label>
			</td>
			<td>
				[checkbox other-income "Disability" "Social Security" "Pension" "Rental Property" "Part-time Job" "Child Support" "Unemployment" "Worker's Compensation"]
			</td>
		</tr>
		<tr>
			<td>
				<label>Spouse (optional)  How often do you get paid? </label>
			</td>
			<td>
				[checkbox spouse-frequency-paid "every week" "every 2 weeks" "twice a month" "monthly"]
			</td>
		</tr>
		<tr>
			<td>
				<label>Net Pay:  (after taxes, medical and other deductions)</label>
			</td>
			<td>
				[text spouse-net-pay]
			</td>
		</tr>
		<tr>
			<td>
				
			</td>
			<td>
				[submit "Submit"]
			</td>
		</tr>
	</tbody>
	
</table>










<!-- REPLY EMAIL -->
<table width="100%" border="0" cellspacing="0" cellpadding="0">
	<tbody>
		<tr>
			<td align="center">
<table width="580" border="0" cellspacing="0" cellpadding="0">
	<tbody>
		<tr>
			<td align="left" valign="top">
				<label>Full Name</label>
			</td>
			<td align="left" valign="top" width="320">
				[full-name]
			</td>
		</tr>
		<tr>
			<td>
				<label>Address</label>
			</td>
			<td>
				[address]
			</td>
		</tr>
		<tr>
			<td>
				<label>Phone</label>
			</td>
			<td>
				[phone]
			</td>
		</tr>
		<tr>
			<td>
				<label>Email Address</label>
			</td>
			<td>
				[your-email]
			</td>
		</tr>
		<tr>
			<td>
				<label>Best time to contact you?</label>
			</td>
			<td>
				[time]
			</td>
		</tr>
		<tr>
			<td>
				<label>What type of bills do you have?<br/>(Check all that apply)</label>
			</td>
			<td>
				[type-bills]
			</td>
		</tr>
		<tr>
			<td>
				<label>Number of bills</label>
			</td>
			<td>
				[number-bills]
			</td>
		</tr>
		<tr>
			<td>
				<label>Amount owed</label>
			</td>
			<td>
				[amount-owed]
			</td>
		</tr>
		<tr>
			<td>
				<label>Appoximate value of home</label>
			</td>
			<td>
				[value-home]
			</td>
		</tr>
		<tr>
			<td>
				<label>Approximate balance on mortgage</label>
			</td>
			<td>
				[mortgage-balance]
			</td>
		</tr>
		<tr>
			<td>
				<label>Monthly mortgage payment</label>
			</td>
			<td>
				[mortgage-payment]
			</td>
		</tr>
		<tr>
			<td>
				<label>Are you up to date on your mortgage payments?</label>
			</td>
			<td>
				[mortgage-up-to-date]
			</td>
		</tr>
		<tr>
			<td>
				<label>Are there any other mortgages on this property?</label>
			</td>
			<td>
				[mortgage-any-other]
			</td>
		</tr>
		<tr>
			<td>
				<h3>Vehicle 1</h3>
			</td>
			<td>
				
			</td>
		</tr>
		<tr>
			<td>
				<label>Year/Make/Model</label>
			</td>
			<td>
				[vehicle-1-ymm]
			</td>
		</tr>
		<tr>
			<td>
				<label>Approximate Value</label>
			</td>
			<td>
				[vehicle-1-value]
			</td>
		</tr>
		<tr>
			<td>
				<label>Approximate Balance</label>
			</td>
			<td>
				[vehicle-1-balance]
			</td>
		</tr>
		<tr>
			<td>
				<label>Monthly Payment</label>
			</td>
			<td>
				[vehicle-1-payment]
			</td>
		</tr>
		<tr>
			<td>
				<label>Are your payments up to date?</label>
			</td>
			<td>
				[vehicle-1-payment-up-to-date]
			</td>
		</tr>
		<tr>
			<td>
				<h3>Vehicle 2</h3>
			</td>
			<td>
				
			</td>
		</tr>
		<tr>
			<td>
				<label>Year/Make/Model</label>
			</td>
			<td>
				[vehicle-2-ymm]
			</td>
		</tr>
		<tr>
			<td>
				<label>Approximate Value</label>
			</td>
			<td>
				[vehicle-2-value]
			</td>
		</tr>
		<tr>
			<td>
				<label>Approximate Balance</label>
			</td>
			<td>
				[vehicle-2-balance]
			</td>
		</tr>
		<tr>
			<td>
				<label>Monthly Payment</label>
			</td>
			<td>
				[vehicle-2-payment]
			</td>
		</tr>
		<tr>
			<td>
				<label>Are your payments up to date?</label>
			</td>
			<td>
				[vehicle-2-payment-up-to-date]
			</td>
		</tr>
		<tr>
			<td>
				<label>Enter any other property of significant value. <br />(For example, if you own a boat, list it here.)</label>
			</td>
			<td>
				[other-property]
			</td>
		</tr>
		<tr>
			<td>
				<label>Are you employed?</label>
			</td>
			<td>
				[employed]
			</td>
		</tr>
		<tr>
			<td>
				<label>How often do you get paid? </label>
			</td>
			<td>
				[frequency-paid]
			</td>
		</tr>
		<tr>
			<td>
				<label>Net Pay: (after taxes, medical and other deductions)</label>
			</td>
			<td>
				[net-pay]
			</td>
		</tr>
		<tr>
			<td>
				<label>What other types of income do you have?  (Check all that apply) </label>
			</td>
			<td>
				[other-income]
			</td>
		</tr>
		<tr>
			<td>
				<label>Spouse (optional)  How often do you get paid? </label>
			</td>
			<td>
				[spouse-frequency-paid]
			</td>
		</tr>
		<tr>
			<td>
				<label>Net Pay:  (after taxes, medical and other deductions)</label>
			</td>
			<td>
				[spouse-net-pay]
			</td>
		</tr>
	</tbody>
	
</table>
		</td>
		</tr>
	</tbody>
</table>



